Objective: To assess the efficacy of a literacy-appropriate weight loss intervention targeting providers and patients in improving physicians' weight loss counseling and patients' self-reported beliefs, and self-efficacy.Methods: The study took place in a public hospital nephrology clinic. The intervention included two physician workshops and a small group patient education. Physician-patient communication was observed and coded. Structured interviews assessed patient recall of weight loss recommendations, weight-related beliefs, and self-efficacy.Results: 64 patient visits were observed before and after the intervention. 75% of patients were African American, 96% lacked private insurance, 71% had low literacy skills; mean body mass index (BMI) of 35 kg/m(2). Physician counseling improved significantly post-intervention, particularly in assessing, supporting and advising patients about weight loss and exercise. Patients reported increases in recall of weight loss recommendations and were more likely to report greater confidence about losing weight (52% vs. 70%, p < 0.01).Conclusions: This pilot study offers promising directions to address provider and patient barriers to weight loss education and counseling in a public hospital.Practice implications: Hospital-based weight loss interventions need to target both physicians and patients. Published by Elsevier Ireland Ltd.

Intradialytic parenteral nutrition (IDPN) has been used as nutritional repletion in severely malnourished patients with end-stage renal disease (ESRD). This study presents a retrospective look at hemodialysis patients with malnutrition who were followed-up in the process of continuous quality improvement (CQI). The costs of intravenous supplies, hospitalizations, and morbidity are reviewed. The application of continuous quality improvement was used to identify and follow-up malnourished patients. There were significant decreases in number of hospitalizations and days in the hospital.

Northeast Louisiana Dialysis Center implemented continuous quality improvement (CQI) to improve the quality of care delivered to end stage renal disease (ESRD) patients treated by hemodialysis in their facility. The unit chose to address normalization of calcium and phosphorus and parathyroid hormone (PTH), anemia, nutrition, adequacy of dialysis and dialyzer reuse as well as performance benchmarks by the Health Care Financing Administration (HCFA) core indicators. This article presents the results obtained and the methodology used in this improvement effort. The article also presents nine principles the authors believe necessary for a successful CQI program.

Many organizations are looking for ways to reduce the cost and improve the quality of open-heart surgery. Fletcher Allen Health Care in Burlington, Vermont used a total quality management approach to do just that. The result was a dramatic improvement in outcomes. Fletcher Allen won the 1994 USA Today Quality Cup for its efforts.

A 30-year-old black male with end-stage renal disease of 8 years' duration had undergone 16 prior access operations and was still without an adequate access for dialysis. A spiral saphenous vein graft conduit was constructed from the left saphenous vein and used as a straight arterial conduit graft between the superficial femoral artery at Hunter's canal and the saphenofemoral vein junction in the groin. The spiral vein graft tube was used as the sole means of dialysis for the next consecutive 750 dialysis procedures over nearly 6 years without any complication.

We studied angiographically the access route 1-27 months after the insertion temporary dialysis catheters in 52 patients: 32 subclavian and 20 internal jugular. The two groups were statistically similar with respect to age, sex and race. The subclavian catheters were left in for a mean of 11.5 days (2-22) while the internal jugular ones were inserted for 15.8 days (5-25; p = 0.0015). One hundred percent of the internal jugular patients were free of any venogram abnormalities in their venous access return. In marked contrast, 50% of the subclavian sites had mild to severe stricutures with 90% having 70-100% occlusion of the subclavian vein. Six patients had bilateral severe strictures. The long-term stricture rate of subclavian catheters in the subclavian vein was unacceptably high compared to the internal jugular route.

The potential contribution of the splanchnic tissues to the carbohydrate intolerance of uremia was studied in fasted, partially nephrectomized rats. The livers of sham operated (C) and partially nephrectomized (Nx) rats were perfused with physiologic concentrations of potential gluconeogenic substrates using a nonrecirculating perfusion apparatus. Glucose release was slightly greater in the livers of Nx rats as compared to C rats. The portal vein concentrations of the potential gluconeogenic precursors were not different in the two groups. Moreover, there were no differences in the net hepatic extraction of alanine, glutamine or glutamate between the two groups of rats. There was also no difference in the production of glucose from U14C alanine. The livers of Nx rats, however, demonstrated less net extraction of lactate and released greater concentrations of betahydroxybutyrate. The increased release of glucose by livers of Nx rats may be at least partially due to their greater hepatic glycogen content.

Use of a new phosphate binder in chronic renal insufficiency. The role of phosphorus retention in the development of secondary hyperparathyroidism in renal failure is well established. Unfortunately, there are no nutritionally complete, palatable, low-phosphorus diets. Thus, phosphorus-binding gels have been prescribed to control phosphorus absorption from the gastrointestinal tract. Most of these binders are aluminum-containing preparations designed to be used as antacids and, as such, were not optimized for high anion binding capacity. We have prepared a new phosphorus binder, an aluminum oxide-based gel, with an increased anion binding capacity. This material (Controphos TM ) was incorporated into breadsticks in order to increase patient tolerance. Toxicologic studies performed in rats indicated that the animals ingesting this experimental binder did not show increased aluminum concentration in the brain. Metabolic studies in which oxygen consumption was determined in cortical renal slices suggested that a decrease in oxygen consumption was due to phosphate deficiency and not to the binder itself. Studies in dialysis patients clearly demonstrated that hyperphosphatemia can be easily corrected. Moreover, balance studies in patients with chronic renal failure indicated that this experimental binder incorporated into breadsticks is as effective as the best available phosphorus binder (aluminum carbonate gel, Basaljel®). When aluminum carbonate gel, however, was incorporated into breadsticks, its capacity to bind phosphorus was greatly reduced. Summary. A new phosphorus binder that retains high binding capacity even when incorporated into breadsticks was well accepted and tolerated by patients with chronic renal failure. Emploi d'un nouveau chelateur du phosphore dans l'insuffisance renale chronique. Le role de la retention de phosphore dans le developpement de l'hyperparathyroidisme secondaire de l'insuffisance renale est bien etabli. Malheureusement il n'existe pas de regimes pauvres en phosphate complets du point de vue nutritionnel et de gout agreable. Par consequent les gels qui se combinent au phosphore ont ete prescrits pour en limiter l'absorption digestive. La plupart de ces substances contiennent d'aluminium, qui a une capacite de liaison aux anions accrue. Cette substance (Controphos TM ) a ete incorporee a des gressins pour en augmenter la tolerance. Les etudes toxicologiques realisees chez le rat indiquent que les animaux qui ingerent cette substance n'ont pas d'augmentation de la concentration cerebrale d'aluminium. Les etudes metaboliques dan lesquelles la consommation d'oxygene de tranches de cortex renal a ete determinee suggerent que la diminution de cette consommation est due au deficit du phosphate et non a la substance ellememe. Les etudes faites chez des malades en dialyse demontrent que l'hyperphosphatemie peut etre facilement corrigee. Les etudes de bilan chez des malades en insuffisance renale chronique indiquent que cette substance incorporee dans des gressins est aussi efficace que le meilleur produit jusque la disponible (gel de carbonate d'aluminium, Basaljel®). Cependant quand ce gel a ete incorpore dans des gressins, sa capacite a lier le phosphore a ete considerablement reduite. En resume, un nouveau chelateur du phosphore, qui conserve sa grande capacite quand il est incorpore a des gressins, a ete bien accepte et supporte par des malades en insuffisance renale chronique.

The liver has been shown to remove parathyroid hormone (PTH) from its arterial circulation by a mechanism that is selective for the intact form of the peptide (PTH 1-84). The present studies demonstrate that PTH has biologic effects on the liver in vivo. Bovine PTH 1-84 stimulated hepatic glucose release in dogs with indwelling hepatic vein catheters from basal values of 31+/-8 to 68+/-9 mg/min per kg after bolus injections of PTH. The effect on hepatic glucose release was apparent by 5 min and persisted for the 80 min of observation. The NH(2)-terminal PTH fragment (syn b-PTH 1-34) had no effect. Bovine PTH 1-84 administered in doses designed to produce circulating levels of immunoreactive PTH similar to the endogenous levels observed in uremic dogs also increased the incorporation of (14)C from infused [(14)C]alanine into glucose, and increased estimated hepatic uptake of both chemical and [(14)C]alanine, while increasing hepatic glucose release. Thus, administration of "physiologic levels" of b-PTH 1-84 stimulated hepatic glucose release in part through increased gluconeogenesis in vivo, whereas syn b-PTH 1-34 had no demonstrable effect. Circulating levels of insulin rose after PTH administration, an increase which presumably represents a secondary response to the rise in glucose release. These results suggest that the liver is a target organ of PTH, and that PTH might potentially alter carbohydrate metabolism during hypersecretion. They also suggest that hepatic uptake of PTH may be related in part to production of a specific biologic effect rather than just simple peptide degradation.

The rate of change of the serum creatinine concentrations in 63 patients with chronic progressive renal disease of varied etiology was examined by linear regression analysis using the logarithm or the reciprocal of the serum creatinine concentration versus time. A single straight line was described by one or the other of these relationships in 53 patients. Six patients had an accelerated rate of nephron destruction terminally (two slopes) regardless of the mathematical analysis. The remaining four patients had course changes either due to apparent spontaneous remissions or temporally related to therapy. These data suggest that (functional) nephron loss in chronic progress disease is orderly and mathematically definable. The theoretical implications are that functional nephron loss is either exponential (log Cr) or constant (1/Cr).

Previous studies from this laboratory demonstrated that secondary hyperparathyroidism in dogs with chronic renal disease may occur, at least in part, as a consequence of the need for progressive adaptation in renal phosphorus (P) excretion that occurs as glomerular filtration rate falls. However, the studies were of relatively short duration. Moreover, no information emerged regarding a potential role of calcium malabsorption in the pathogenesis of secondary hyperparathyroidism. The short duration of the protocol did not lend itself to the study of the effect of P control or the administration of vitamin D in the pathogenesis of renal osteodystrophy. In the present studies, 14 dogs with experimental chronic renal disease were studied serially for a period of 2 yr. Each animal was studied first with two normal kidneys on an intake of P of 1,200 mg/day. Then, renal insufficiency was produced by 5/6 nephrectomy. The dogs then were divided into three groups. In group I, 1,200 mg/day P intake was administered for the full 2 yr. In group II, P intake was reduced from the initial 1,200 mg/day, in proportion to the measured fall in glomerular filtration rate, in an effort to obviate the renal adaptation in P excretion. In group III, "proportional reduction" of P intake also was employed; but in addition, 20 mug of 25(OH)D(3) were administered orally three times a week. In group I, parathyroid hormone (PTH) levels rose throughout the 2-yr period reaching a final concentration of 557+/-70 U (normal 10-60). In group II, values for PTH remained normal throughout the 1st yr, increased modestly between the 12th and the 18th mo, but then did not rise after the 18th mo. In group III, no elevation of PTH levels was observed at any time; however, these animals were hypercalcemic. Histomorphologic analyses of the ribs of these dogs were performed serially throughout the 2-yr period. A linear relationship was obtained between the osteoclastic resorption surface and the concentration of circulating immunoreactive PTH. The osteoid volume was greater in group I animals when compared to those in group II. None of the morphologic abnormalities associated with renal osteodystrophy were observed in the animals in the third group.